Acute colonic pseudo-obstruction post-cesarean section is not a benign entity: A case series and review of the literature

Acute colonic pseudo-obstruction (ACPO) is an infrequent occurrence after cesarean section. Anecdotal evidence suggests that the clinical course of ACPO in the obstetric setting is different to that seen in non-pregnant adult patients with ACPO secondary to alternative causes, such as systemic illnesses, the use of certain medications, and after non-abdominal surgery. The risk of progression to ischemia and perforation, as well as the need for emergency surgery, appears to be higher after cesarean section. Here we describe the clinical course of ACPO in four patients after cesarean section from our institution, followed by a review of the literature and a discussion of the important issues surrounding this condition in the postpartum time period. The findings from our cohort of patients and the reports from the medical literature support a hands-on combined approach from a group of specialists including obstetricians, surgeons, radiologists, and enterostomal therapists. Immediate imaging followed by regular observation is mandatory for any patient being managed conservatively. Early use of endoscopic decompression should be considered for patients who are not resolving with a conservative approach. Clinical signs of peritonism or radiological signs of ischemia or perforation in patients with ACPO mandate immediate surgical intervention. Appropriate postoperative care is necessary to deal with the complex physiological and psychological consequences of emergency surgery and potential stoma formation so soon after cesarean section.

An ethnographic study evaluating emergency obstetric care education and training in a remote, fragile region of Southeast Asia: Study protocol

AIM

To evaluate emergency obstetric care education and training within a medical assistant training program, being delivered in a remote, fragile region of Southeast Asia. This will aid in the identification of potential areas of enhancement to improve the management of obstetric emergencies.

DESIGN

An ethnographic study, adopting a multi-methods approach.

METHODS

Emergency obstetric care education and training will be assessed through documentary analysis and interviews (online or face-to-face) with educators and trainers (N ~ 6-7). Student experiences will be explored using in-person focus groups, facilitated by an external trainer involved in delivering the program (N ~ 10-12). A reflective field diary will provide insight into the lived experience of postgraduate students (N ~ 4-5). Data will be collected between May 2022 and May 2023. The full data set will be triangulated and analysed using the READ approach; (1) ready your materials, (2) extract data, (3) analyse data and (4) distil your findings. Institutional ethical approval was obtained from a university in October 2021, and inter-country regional access was gained following adherence to their local ethical requirements.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The findings from this study may help to inform the future design of the medical assistant training program. It is anticipated that the knowledge gained from this study will enhance the education and training of mid-level health providers at local, national, and international levels. This work intends to contribute to addressing Sustainable Development Goal 3, Target 1 of reducing maternal mortality to 70:100,000 live births in low-income countries.

REPORTING METHOD

This protocol adhered to the Standards for Reporting Qualitative Research (SRQR) checklist.

PATIENT OR PUBLIC CONTRIBUTION

No formal PPI has been undertaken; however, stakeholders involved in delivering the education and training have been consulted.

Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America

OBJECTIVE

To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country.

METHODS

Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period.

RESULTS

We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00).

CONCLUSION

The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.

Knowledge of Critical Issues in the Intrapartum Period: a Cross-sectional Study Among Undergraduate Final Year Midwifery Students

Background

Dealing with critical issues in the intrapartum period requires comprehensive knowledge and a full understanding of the basic principles and skills involved, as complications during labor and birth occur unexpectedly..

Objective

The aim of this study was to evaluate the knowledge of critical issues in the intrapartum period among undergraduate final year midwifery students.

Methods

This is a descriptive observational cross-sectional study conducted between February-July 2017. Final year undergraduate midwifery students were recruited from one institution and four public hospitals. The research instrument was a questionnaire designed by the research team. Statistical significance was set at p<0.05 and analyses were performed using the IBM SPSS Statistics version 22.

Results

The final study sample consisted of 100 participants. The 36.0% of the students had started their final year internship, with a mean duration of 4.3 months. Only 2% of the participants had obtained a bachelor degree from another department, 76% had attended general high school, 17% had pre-graduate work experience and 48.0% had attended a seminar on critical issues in the intrapartum period. Participants' final scores ranged from 5% to 90%, with mean value being 49.7% (SD=16.5%). The knowledge score was found to be significantly higher in midwifery students who had started the internship. However, it was not significantly correlated with other educational characteristics. Finally, no significant correlation was observed between knowledge score and age (r= -0.15, p=0.138) or knowledge score and months of internship (r=0.27, p=0.114).

Conclusion

In the core midwifery curriculum, the design and integration of didactic and clinical courses focusing on emergency management in midwifery practice is considered of paramount importance. However, teachers should provide midwifery students with guidance on independent learning ability and implement effective strategies to enhance students' self-study skills.

Efficacy of capacity building educational interventions in the management of obstetric complications: A systematic review

BACKGROUND

Delay in the diagnosis and management of obstetric complications lead to raised mortality rate. This can be curtailed by appropriate implementation of the educational intervention among the health-care providers. Hence, this review aimed to identify the literature evidence of the efficacy of various educational interventions training in the management of obstetric complications.

MATERIALS AND METHODS

We searched PUBMED, Web of Science, SCOPUS, Google Scholar, Cochrane, and maternity care databases with studies published from 2011 to 2021 for identifying studies related to this educational intervention review using MeSH terms and free terms. The search process was also done on the websites of the World Health Organization and the reproductive health library in the English language. From the 1823 abstracts reviewed, 16 studies were included (15 quasi-experimental, 01 randomized clinical trial, and 01 exploratory research design). We identified studies that included skill assessment of nurses, midwives, auxilliary nurse-midwives (ANMs), medical students, interns, and doctors after implementing various educational interventions.

RESULTS

According to the findings of this literature, achieving enhanced nursing management of obstetric complications has been developed. Especially, it suggests through better nursing training and education and also by providing sufficient resources, time, and coordination with obstetric specialists, nurses and midwives will be able to implement their care roles, which include proper diagnosis, appropriate intervention, advanced care, client education, and psychological support. The efficacy of each educational intervention varies and depends on the participants' understanding, interest, and the advancement of the teaching-learning method used.

CONCLUSION

This systematic review reveals abroad and logical move towards the evaluation of various educational interventions in the field of obstetric complications. Among all the educational interventions implemented, mobile application, and simulation-based training play a major role in improving the knowledge and skills of health-care providers in the management of obstetric complications.

Cesarean birth, obstetric emergencies, and adverse neonatal outcomes in Iceland during a period of increasing labor induction

BACKGROUND

The rate of labor induction has risen steeply throughout the world. This project aimed to estimate changes in the rates of adverse maternal and neonatal outcomes in Iceland between 1997 and 2018, and to assess whether the changes can be explained by an increased rate of labor induction.

METHODS

Singleton live births, occurring between 1997 and 2018, that did not start by prelabor cesarean, were identified from the Icelandic Medical Birth Register (n = 85 971). Rates of intrapartum cesarean birth (CB), obstetric emergencies, and neonatal outcomes were calculated, and adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) were estimated with log-binomial regression (reference: 1997-2001). Adjustments were made for: (a) maternal characteristics, and (b) labor induction and gestational age.

RESULTS

The rate of labor induction increased from 13.6% in the period 1997-2001 to 28.1% in the period 2014-2018. The rate of intrapartum CB decreased between the periods of 1997-2001 and 2014-2018 for both primiparous (aRR 0.76, 95% CI: 0.69 to 0.84) and multiparous women (aRR 0.55, 95% CI: 0.49 to 0.63). The rate of obstetric emergencies and adverse neonatal outcomes also decreased between these time periods. Adjusting for labor induction did not attenuate these associations.

CONCLUSIONS

The rates of adverse maternal outcomes and adverse neonatal outcomes decreased over the study period. However, there was no evidence that this decrease could be explained by the increased rate of labor induction.

The stress of the midwife: Experiences of advanced midwives working in obstetric emergency units in Johannesburg, South Africa

Obstetric emergencies account for the majority of causes of maternal deaths. The major causes of maternal and neonatal deaths in obstetric emergencies include bleeding, pregnancy-induced hypertension, cord prolapse, shoulder dystocia, poor progress, placenta abruptio, placenta praevia and amniotic fluid embolism. These adverse labour and birth events cause emergency situations and trauma for the nursing staff involved. A qualitative, descriptive phenomenological research design was used to explore and describe the lived experiences of advanced midwives regarding the management of obstetric emergencies in Midwife Obstetric Units (MOUs) of Gauteng Province, South Africa. An interview guide was prepared with a major question which was followed by probing questions based on the participant's responses. Semi-structured, face-to-face individual interviews were used to collect data from thirteen (13) advanced midwives who were purposively selected and had been working in the Midwife Obstetric Units for two years or more after obtaining their qualifications. The Midwife Obstetric Units were selected based on the records of their birth statistics. The seven Collaizi's procedural steps were utilised for data analysis. Measures to ensure the trustworthiness of the study were observed within the naturalistic paradigm comprising criteria of credibility; transferability; dependability; and confirmability. Three themes with sub-themes emerged from the current study, namely: psychosocial stress; advanced midwives' workload; and lack of professionalism. In conclusion, it was evident that advanced midwives experience psychosocial stress because of unconducive working environments which are not adequately resourced, and high expectations from patients and their families. Management should support advanced midwives with the necessary resources that will enable them to perform their duties effectively and minimise their levels of stress and trauma.

Liver diseases in pregnancy

Liver disease in pregnancy can be related to a pre-existing condition (such as autoimmune liver disease) or arise as a consequence of pregnancy. In women with pre-existing disease, pre-pregnancy counselling is important to discuss the potential complications that may occur during pregnancy and how best to manage these. Acute fatty liver of pregnancy and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome are pregnancy-related liver diseases and are considered obstetric emergencies. Women with liver dysfunction need appropriate investigations, including blood tests and imaging. They should be managed as part of a multidisciplinary team with obstetricians, obstetric anaesthetists, specialist midwives, gastroenterologists and obstetric physicians.

Stakeholders' Perspectives on the Challenges of Emergency Obstetric Referrals and the Feasibility and Acceptability of an mHealth Intervention in Northern Iraq

The health system in northern Iraq has been weakened by conflict and the internal displacement of over three million people. Mobile phone-based interventions (mHealth) may improve maternal and neonatal health outcomes by enabling emergency referrals, facilitating communication between patients and providers, and improving patient data management; however, they have not been sufficiently studied in conflict-affected settings. We explored stakeholders' perspectives on challenges to obstetric referrals and the feasibility and acceptability of a mobile phone-based application to reduce delays in reaching emergency obstetric care in order to inform its development. We conducted a qualitative study in the Kurdistan region of northern Iraq from May to July, 2018. Using purposive sampling, we carried out 15 semi-structured interviews with coordination actors including healthcare management staff, government health officials, non-government health program managers and ambulance staff. The interviews explored obstetric care delivery, referral processes, mobile phone usage and mHealth implementation strategies. Eleven focus group discussions, which incorporated participatory activities on similar topics, were conducted with ambulance drivers, hospital and primary health center staff. Audio-recorded, transcribed and translated data were coded iteratively to identify emerging concepts, and analyzed thematically. Sixty-eight stakeholders (36 women and 32 men) participated. Challenges regarding the referral system included resource limitations, security concerns, costs and women's reluctance to be transported in male-staffed ambulances. In terms of obstetric care and decision-making, participants noted gaps in communication and coordination of services with the current paper-based system between health care providers, ambulance drivers, and hospital staff. Ambulance drivers reported incurring delays through lack of patient information, poor road conditions, and security issues. A prototype mobile phone application was found to be acceptable based on perceived usefulness to address some of the challenges to safe obstetric care and focused on phone usage, access to information, Global Positioning System (GPS), connectivity, cost, and user-friendliness. However, the feasibility of the innovation was considered in relation to implementation challenges that were identified, including poor connectivity, and digital literacy. Implementation of the app would need to account for the humanitarian context, cultural and gender norms regarding obstetric care, and would require substantial commitment and engagement from policymakers and practitioners.

Interdepartmental Collaboration for Simulation-based Education: Obstetric Emergencies for Emergency Medicine

BACKGROUND

Simulation in medical education is a well-accepted educational modality that allows for practice of high risk, low frequency events. The Obstetric Emergencies for Emergency Medicine course was developed to prepare trainees for challenging scenarios.

METHODS

Six clinical scenarios were chosen: spontaneous vaginal delivery, neonatal resuscitation, pre- eclampsia, neonatal resuscitation with cardiopulmonary resuscitation (CPR), shoulder dystocia and postpartum hemorrhage. Development and facilitation was an interdepartmental effort with contributions from Emergency Medicine, Obstetrics and Gynecology, and Pediatric Emergency Medicine. Each case was allotted 35 minutes, including debriefing. Participants completed an evaluation survey for each scenario.

RESULTS

All participants responded yes to the question "Would you recommend this simulation become part of the standard curriculum." The means of ratings for "scenario overall" and "relevance to training/duties" ranged from 4.95-5 out of 5 across all simulation groups.

CONCLUSION

An interdepartmental and collaborative approach can optimize the success of a simulation educational program.

Caval Aortic Index: A Novel Tool for Fluid Assessment in Obstetric Emergencies

Background:

Uncorrected maternal hypotension occurring during obstetric emergencies may result in maternal and fetal morbidity. Fluid status of the pregnant mother is a major variable which affects the maternal hemodynamics during patient management, and there is no objective assessment tool for the same. A relatively new sonographic parameter, the inferior vena cava aorta (IVC/Ao) diameter index or caval aortic index, showed promise in this regard, and its application was studied in obstetric patients.

Methodology:

A prospective analytical study was conducted involving 50 pregnant and 50 nonpregnant women of reproductive age group. Using both subxiphoid and transhepatic views, their normal fasting caval aortic indices were determined from the ratio of mean IVC diameter to the mean aortic diameter. Descriptive and inferential statistical analyses were carried out accordingly.

Results:

Normal IVC/Ao diameter index for nonpregnant healthy women of reproductive age was 1.11 ± 0.29 in the subxiphoid view and 1.21 ± 0.33 in the transhepatic view. The difference between the two views was not statistically significant. IVC/Ao diameter index for a normal term pregnant woman was 1.03 ± 0.26, and term pregnancy does not significantly cause variation in the index.

Conclusions:

Caval aortic index is a useful noninvasive tool to assess volume status and guide fluid management in pregnant women presenting to the emergency department, and the transhepatic view is comparable to the traditional subxiphoid view for the measurement of the same.

Obstetric emergencies as antecedents to neonatal hypoxic ischemic encephalopathy, does parity matter?

INTRODUCTION

Our aim was to investigate the risk of moderate to severe hypoxic ischemic encephalopathy (HIE) by obstetric emergencies, with focus on the distribution of obstetric emergencies by parity, taking the history of a previous cesarean into account.

MATERIAL AND METHODS

Population-based cohort study of 692 428 live births at ≥ 36 weeks of gestation in Sweden, 2009-2015. Data were retrieved by linking the Swedish Medical Birth Register with the Swedish Neonatal Quality Register. Therapeutic hypothermia served as surrogate for moderate to severe HIE. Logistic regression analysis was used to estimate associations between HIE and placental abruption, eclampsia, cord prolapse, uterine rupture, and shoulder dystocia, presented as adjusted odds ratios (aORs) with 95% CI.

RESULTS

An obstetric emergency occurred in 133/464 (29%) of all HIE cases, more commonly in the parous (overall 37%; 48% with and 31% without a previous cesarean) than in the nulliparous (21%). Among nulliparas, shoulder dystocia was the most common obstetric emergency with the strongest association with HIE (aOR 48.2; 95% CI 28.2-82.6). In parous women without a previous cesarean, shoulder dystocia was most common, but placental abruption had the strongest association with HIE. Among parous women with a previous cesarean, uterine rupture was the most prevalent obstetric emergency with the strongest association with HIE (aOR 45.6; 95% CI 24.5-84.6).

CONCLUSIONS

Obstetric emergencies are common among cases of moderate to severe HIE. The strong association with shoulder dystocia in nullipara, and with uterine rupture in women with previous cesarean deliveries, implies an opportunity for reducing the incidence of HIE.

Design of a Serious Game for Handling Obstetrical Emergencies

Background

The emergence of new technologies in the obstetrical field should lead to the development of learning applications, specifically for obstetrical emergencies. Many childbirth simulations have been recently developed. However, to date none of them have been integrated into a serious game.

Objective

Our objective was to design a new type of immersive serious game, using virtual glasses to facilitate the learning of pregnancy and childbirth pathologies. We have elaborated a new game engine, placing the student in some maternity emergency situations and delivery room simulations.

Methods

A gynecologist initially wrote a scenario based on a real clinical situation. He also designed, along with an educational engineer, a tree diagram, which served as a guide for dialogues and actions. A game engine, especially developed for this case, enabled us to connect actions to the graphic universe (fully 3D modeled and based on photographic references). We used the Oculus Rift in order to immerse the player in virtual reality. Each action in the game was linked to a certain number of score points, which could either be positive or negative.

Results

Different pathological pregnancy situations have been targeted and are as follows: care of spontaneous miscarriage, threat of preterm birth, forceps operative delivery for fetal abnormal heart rate, and reduction of a shoulder dystocia. The first phase immerses the learner into an action scene, as a doctor. The second phase ask the student to make a diagnosis. Once the diagnosis is made, different treatments are suggested.

Conclusions

Our serious game offers a new perspective for obstetrical emergency management trainings and provides students with active learning by immersing them into an environment, which recreates all or part of the real obstetrical world of emergency. It is consistent with the latest recommendations, which clarify the importance of simulation in teaching and in ongoing professional development.

Effect of Nurse-Led Review Plus Simulation on Obstetric/Perinatal Nurses' Self-Assessed Knowledge and Confidence

Simulation may help both novice and experienced clinicians maintain competence in managing high-risk, low-frequency obstetric and perinatal complications and emergencies. Therefore, we designed a pre-/posttest study to determine whether a day of nurse-led lecture plus low-fidelity simulation would increase registered nurses' self-assessed knowledge and confidence in managing five high-risk obstetric/perinatal situations. The Nursing Management of OB/Perinatal Complications & Emergencies (NursOB) scale was distributed to 67 labor/birth and postpartum nurses before and after a simulation training day. Preliminary findings supported validity and reliability of the NursOB scale, but nurses' knowledge and confidence did not improve after the simulation (p < .05). Anecdotally, nurses' interest in competence reviews was reinvigorated, and we gained practical knowledge in simulation delivery. Future simulations could enhance outcome measures, improve drills, and establish criterion-related validity of the NursOB scale. More research is warranted.

Effective interprofessional simulation training for medical and midwifery students

Introduction

Good interprofessional teamworking is essential for high quality, efficient and safe clinical care. Undergraduate interprofessional training has been advocated for many years to improve interprofessional working. However, few successful initiatives have been reported and even fewer have formally assessed their educational impact.

Methods

This was a prospective observational study of medical and midwifery students at a tertiary-level maternity unit. An interprofessional training module was developed and delivered by a multiprofessional faculty to medical and midwifery students, including short lectures, team-building exercises and practical simulation-based training for one obstetric (shoulder dystocia) and three generic emergencies (sepsis, haemorrhage, collapse). Outcome measures were interprofessional attitudes, assessed with a validated questionnaire (UWE Interprofessional Questionnaire) and clinical knowledge, measured with validated multiple-choice questions.

Results

Seventy-two students participated (34 medical, 38 midwifery). Following training median interprofessional attitude scores improved in all domains (p<0.0001), and more students responded in positive categories for communication and teamwork (69-89%, p=0.004), interprofessional interaction (3-16%, p=0.012) and interprofessional relationships (74-89%, p=0.006). Scores for knowledge improved following training for medical students (65.5% (61.8-70%) to 82.3% (79.1-84.5%) (median (IQR)) p<0.0001) and student midwives (70% (64.1-76.4%) to 81.8% (79.1-86.4%) p<0.0001), and in all subject areas (p<0.0001).

Conclusions

This training was associated with meaningful improvements in students' attitudes to teamwork, and knowledge acquisition. Integrating practical tasks and teamwork training, in authentic clinical settings, with matched numbers of medical and non-medical students can facilitate learning of both why and how to work together. This type of training could be adopted widely in undergraduate healthcare education.

Myths and realities of training in obstetric emergencies

Training for intrapartum emergencies is a promising strategy to reduce preventable harm during birth; however, not all training is clinically effective. Many myths have developed around such training. These principally derive from misinformed beliefs that all training must be effective, cheap, independent of context and sustainable. The current evidence base for effective training supports local, unit-based and multi-professional training, with appropriate mannequins, and practice-based tools to support the best care. Training programmes based on these principles are associated with improved clinical outcomes, but we need to understand how and why that is, and also why some training is associated with no improvements, or even deterioration in outcomes. Effective training is not cheap, but it can be cost-effective. Insurers have the fiscal power to incentivise training, but they should demand the evidence of clinical effect; aspiration and proxies alone should no longer be sufficient for funding, in any resource setting.

Factors influencing modes of transport and travel time for obstetric care: a mixed methods study in Zambia and Uganda

Transportation is an important barrier to accessing obstetric care for many pregnant and postpartum women in low-resource settings, particularly in rural areas. However, little is known about how pregnant women travel to health facilities in these settings. We conducted 1633 exit surveys with women who had a recent facility delivery and 48 focus group discussions with women who had either a home or a facility birth in the past year in eight districts in Uganda and Zambia. Quantitative data were analysed using univariate statistics, and qualitative data were analysed using thematic content analysis techniques. On average, women spent 62-68 min travelling to a clinic for delivery. Very different patterns in modes of transport were observed in the two countries: 91% of Ugandan women employed motorized forms of transportation, while only 57% of women in Zambia did. Motorcycle taxis were the most commonly used in Uganda, while cars, trucks and taxis were the most commonly used mode of transportation in Zambia. Lower-income women were less likely to use motorized modes of transportation: in Zambia, women in the poorest quintile took 94 min to travel to a health facility, compared with 34 for the wealthiest quintile; this difference between quintiles was ∼50 min in Uganda. Focus group discussions confirmed that transport is a major challenge due to a number of factors we categorized as the 'three A's:' affordability, accessibility and adequacy of transport options. Women reported that all of these factors had influenced their decision not to deliver in a health facility. The two countries had markedly different patterns of transportation for obstetric care, and modes of transport and travel times varied dramatically by wealth quintile, which policymakers need to take into account when designing obstetric transport interventions.

Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators

BACKGROUND

Ineffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a highly-realistic, low-tech simulation-based obstetric and neonatal emergency training program. A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico, with pre/post measurement of process indicators at intervention hospitals. This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators.

METHODS

Data was collected in twelve intervention facilities on process indicators, including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation, achievement of strategic planning goals established during training and changes in teamwork scores. Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement.

RESULTS

A total of 450 professionals in interprofessional teams were trained. Significant increases in knowledge and self-efficacy were noted for both physicians and nurses (p <0.001- 0.009) in all domains. Teamwork scores improved and were maintained over a three month period. A mean of 58.8% strategic planning goals per team in each hospital were achieved. There was no association between high goal achievement and knowledge, self-efficacy, proportion of doctors or nurses in training, state, or teamwork score.

CONCLUSIONS

These results suggest that PRONTO's highly realistic, locally appropriate simulation and team training in maternal and neonatal emergency care may be a promising avenue for optimizing emergency response and improving quality of facility-based obstetric and neonatal care in resource-limited settings.

TRIAL REGISTRATION

NCT01477554.

'In situ simulation' versus 'off site simulation' in obstetric emergencies and their effect on knowledge, safety attitudes, team performance, stress, and motivation: study protocol for a randomized controlled trial

BACKGROUND

Unexpected obstetric emergencies threaten the safety of pregnant women. As emergencies are rare, they are difficult to learn. Therefore, simulation-based medical education (SBME) seems relevant. In non-systematic reviews on SBME, medical simulation has been suggested to be associated with improved learner outcomes. However, many questions on how SBME can be optimized remain unanswered. One unresolved issue is how 'in situ simulation' (ISS) versus 'off site simulation' (OSS) impact learning. ISS means simulation-based training in the actual patient care unit (in other words, the labor room and operating room). OSS means training in facilities away from the actual patient care unit, either at a simulation centre or in hospital rooms that have been set up for this purpose.

METHODS AND DESIGN

The objective of this randomized trial is to study the effect of ISS versus OSS on individual learning outcome, safety attitude, motivation, stress, and team performance amongst multi-professional obstetric-anesthesia teams.The trial is a single-centre randomized superiority trial including 100 participants. The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet, Copenhagen, who were working on shifts and gave written informed consent. Exclusion criteria were managers with staff responsibilities, and staff who were actively taking part in preparation of the trial. The same obstetric multi-professional training was conducted in the two simulation settings. The experimental group was exposed to training in the ISS setting, and the control group in the OSS setting. The primary outcome is the individual score on a knowledge test. Exploratory outcomes are individual scores on a safety attitudes questionnaire, a stress inventory, salivary cortisol levels, an intrinsic motivation inventory, results from a questionnaire evaluating perceptions of the simulation and suggested changes needed in the organization, a team-based score on video-assessed team performance and on selected clinical performance.

DISCUSSION

The perspective is to provide new knowledge on contextual effects of different simulation settings.

TRIAL REGISTRATION

ClincialTrials.gov NCT01792674.

Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe

BACKGROUND

The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe.

OBJECTIVES

The objectives were to ascertain and compare policies for management of the third stage of labour and immediate management of postpartum haemorrhage in maternity units in Europe following vaginal birth.

DESIGN

Survey of policies.

SETTING

The project was a European collaboration, with participants in 14 European countries.

SAMPLE

All maternity units in 12 countries and in selected regions of two countries in Europe.

METHODS

A postal questionnaire was sent to all or a defined sample of maternity units in each participating country.

MAIN OUTCOME MEASURES

Stated policies for management of the third stage of labour and the immediate management of postpartum haemorrhage.

RESULTS

Policies of using uterotonics for the management of the third stage were widespread, but policies about agents, timing, clamping and cutting the umbilical cord and the use of controlled cord traction differed widely. For immediate management of postpartum haemorrhage, policies of massaging the uterus were widespread. Policies of catheterising the bladder, bimanual compression and in the choice of drugs administered were much more variable.

CONCLUSIONS

Considerable variations were observed between and within countries in policies for management of the third stage of labour. Variations were observed, but to a lesser extent, in policies for the immediate management of postpartum haemorrhage after vaginal birth. In both cases, policies about the pharmacological agents to be used varied widely.